Interprofessional is a term used to describe professionals from different disciplines working in collaboration to achieve mutually agreed goals for clients, patients or service users. In this essay I am going to look at the current health and social care context in which the government is advocating interprofessional working. I will discuss the benefits of interprofessional working drawing on examples from my own collaborative group work. I will also examine some of the difficulties and barriers to collaborative working, using my groupwork as an illustration of difficulties that may arise when working with other professionals who have differing values and perspectives, and issues associated with power relations within groups.
The promotion of interprofessional working in the delivery of health and social care has long been regarded by planners and practitioners as of great importance, in order to provide a better quality of service. This has been highlighted in UK government policy over the last decade. When New Labour was elected in 1997, they began to make a series of policy changes in health and social care. The government recognised that there was a clear boundary between these two services. It called upon the NHS and local authorities to forge partnerships and break down organisational barriers (Department of Health, 1997). Many people had complex needs spanning across the health services and social services, but found themselves receiving inadequate care due to ‘sterile arguments about boundaries’. New government incentives would encourage joint working to improve all aspects of health and social care through pooled budgets, lead commissioning and integrated provision (Department of Health, 1998).
These measures were followed by the publication of the NHS Plan (Department of Health, 2000a). The report said that the system at the time was too disjointed with too many organisational barriers, and outlined the ways in which it hoped the divisions between health and social care would be overcome. Repeated assessments, often by different agencies, and complex navigation round the care system, were incompatible with a quality service. (Department of Health, 2000b) The report indicated that health would take over much of the responsibilities of social services for elderly and disabled people, while child care might be overseen by the home office.
The report said that social services should, in future, be delivered in new settings, such as GPs’ surgeries, as part of a single local care network. There should be rapid response teams, made up of nurses, care workers, social workers, therapists and GP’s which would provide emergency care at home. Integrated care teams should ensure that people receive the care they need after being discharged from hospital and health and social care professions should have the same assessment frameworks. Primary care trusts create opportunities for closer working between health and social services. The report said that they would, in future, go further than this. Some would be established jointly by health and social services authorities, and some would be imposed by the Department of Health where it was felt local arrangements for collaborative working was required. Incentive payments would be made to encourage and reward joint working.
Some benefits of interprofessional working are identified in a report produced by Cook et al (2001). The paper draws on the findings of two studies examining team working arrangements, and reports on evaluations of decision making in different types of interdisciplinary teams.
The first study discussed in the report focussed on a Community Mental Health Team comprised of social workers, GP attached social workers, community psychiatric nurses, community support workers, and health and social service managers. The second study focussed on Integrated Community Nursing Teams, which were comprised mainly of district nurses, health visitors and practice nurses attached to a particular general practice. The intention of establishing these teams was to develop a model of collaborative working in order to improve client care. Decision-making was a central issue in both of the studies. Although the compositions of the two teams were different, and their aims were varied, there were a number of common issues identified relating to decision-making. Two types of decision-making were noticeable, those relating to clients, and those which led to changes in working practices.
One benefit of interprofessional working relating to decision making identified in the studies was to do with the sharing of information within the teams. This was most clearly illustrated in the Community Mental Health Team. In this team the role of the Community Support Workers was to develop close working relationships with clients, enabling them to acquire a detailed knowledge of the client’s needs and wishes. This allowed them to provide information about the client to other members of the team, in order to provide a more effective service. The capacity for information sharing was improved by the physical closeness of the team members. In both studies, teams were in shared offices or premises. This enabled team members to see each other more often and provide opportunities for informal information sharing, resulting in quicker response times and more efficient working.
The teams in the studies all comprised of different professions with a diversity of knowledge, skills and experience. This provided an extensive expert knowledge base which all team members could draw from. Team members were able to seek advice from a wide range of professionals when solving problems or making decisions regarding service users’ care, where before they may have only sought the advice of their immediate colleagues. Another advantage of the team working looked at in the studies was the fact that team membership provided access to wider professional networks, allowing wider availability of resources within multi-disciplinary teams, and creating more resourcefulness in problem solving.
Another benefit of interprofessional working identified in the report was that the team members felt more confident in their decision-making as they had back-up and support from colleagues. This allowed team members to make better contributions to the overall service provision, thus providing a more effective service to the client. This ties in with my own experience of the groupwork carried out through the module. We entered the group as a group of social workers amongst people from different disciplines who we’d never met before. This made us feel more confident in our contributions to the group as we had support from our fellow students.
Overall the studies showed that interprofessional working allows for much more effective decision making. Through working in teams, the time taken to make decisions was reduced. Practitioners were able to make decisions with the support of their teams, which allowed for more ‘risky’ decisions to be made more swiftly and confidently. Practitioners benefited from the range of knowledge and skills inherent in multi-disciplinary teams, and service user’s received a better service because of this.
The benefit of speedier decision-making was also noticeable in our groupwork sessions undertaken for the module. We were set a task entitled ‘Meccano Man’, in which we had to replicate a model made from meccano. We had to put it together in room, with the meccano man we were meant to be copying placed in the corridor outside. Only one member of the team was allowed out of the room to look at it at a time. Group members used their communication skills and took on different roles in order to complete the task, each person bringing their individual skills to the team. At the end of the activity we identified that a team approach to this task was much quicker and more effective than if we had had to do it individually.
More benefits of interprofessional working are outlined in ‘What Lies Underneath? An Inter-organisational Analysis of Collaboration between Education and Social Work’ which is written by Nadia Farmakopoulou. The paper examines interprofessional working in special educational needs assessments, and discusses Scottish government policy which has attempted to develop inter-agency collaboration. The paper draws upon data from a study carried out in 1998 and 1999 in three education and social services authorities in Scotland.
The paper says that the government have made interprofessional working a regular feature of policy since the Warnock Committee Report (Department of Education and Science, 1978). The Warnock Report recommended that Education authorities should seek the involvement of Social Services departments in making assessments for children with special educational needs. The report says that this is necessary in order to allow for social workers to make valuable contributions if they wish to do so, and also to provide social work support to the families concerned if this is required. The recommendations were approved and put in the 1980 Education Acts. Research commissioned by the government following this, however, found that the inter-agency cooperation desired was not taking place, and so this was re-emphasised in the Scottish Office Circular 4/96:
Well structured assessment procedures can ensure children are properly catered for in their first years at school, and that their needs are provided for promptly and appropriately. This requires close co-operation between parents and all the statutory agencies and a full understanding by each of the participants of the part that they, and others, play in the process. (Para. 67, p17)
The 1995 Children (Scotland) Act put a duty on education and social work departments to make known their plans to assess children with special educational needs in order for joint assessments to take place. It also requires education, health and social services departments to collaborate in order to produce a Children’s Services Plan. This is further encouragement to develop better interprofessional working.
All the participants from the education and social work departments in the study stated several advantages of inter-agency collaboration. Three different types of benefits were agreed upon by all involved: Professional benefits or benefits to the department such as joint assessments, which are more cost effective; altruistic benefits or benefits for children and their families such as holistic assessment and the best provision of services; and personal benefits such as job satisfaction and support from colleagues. Most respondents said that the benefits of interprofessional working outweighed the disadvantages.
There is a wealth of academic literature which discusses the disadvantages and difficulties associated with interprofessional working. It should not be assumed that simply instructing professionals to work together will be adequate to result in effective teams which provide improved services. A variety of barriers to interdisciplinary working exist that hinder the developments of close collaborative relationships. Hudson (2002) outlines some barriers to effective interprofessional working relating to relationships between members of different professions. One problem that he notes is that the nature of professional identity is such that where members of a certain profession have similar or shared values, perceptions and experiences, there will be more agreement between members of a profession than between members of different professions. This ‘disagreement’ shapes interprofessional relationships, and is likely to cause problems within multi-disciplinary team working. This is something which was noticeable in our own groupwork carried out during the module. Social work teaches similar values to nursing, but the emphasis is different in each profession. During the tasks we carried out as a team in our group sessions, some ethical issues arose, and there were some difficulties which arose through working with students with different perspectives to ourselves.
Irvine et al (2002) note that differing value systems between professions may also contribute to problems with the determining of priority of certain cases. Different professions will see clients’ needs as being at different levels of importance as their aims and goals will be different. This will create problems and sources of conflict between different professions, and some professionals may feel as though their client’s needs are being ignored or devalued. McCray (2002) supports this view. She says that social workers, for example, may be more concerned with achieving outcomes for service users based on a recognition of oppression and inequality in society. Physiotherapists on the other hand, may be focussed more on psychological factors in their work with clients. If these different values are ignored this will create tension within teams Sheppard (1996) also discusses ethical issues as potential sources of conflict. GP’s, for example, will see the life of the patient as their top priority, whereas a social workers’ main concern would be the wishes and feelings of the client. Sheppard says that this could lead to conflict over the clinical treatment of the patient, particularly if they have a mental illness or learning difficulties. Another example is where older people need to be discharged from hospital. The hospital consultant may think they should go into a nursing home, whereas the older person may want to go back to their own home. This could cause conflicts between all professionals involved.
Hudson also explains that issues to do with professional status also have implications for interprofessional relationships. Health and social care professions in particular have very different levels of training, education and legal restriction. For example doctors are widely seen as ‘full’ professionals, whereas social workers and nurses are mainly seen as ‘semi-professional’, due to the perceived limitations of their knowledge-base, training and autonomy (Etzioni, 1969). Although the status of nursing and social work has been improved in recent years, they are both still seen as inhibited by state bureaucracies. Such a degree of lack of autonomy is not compatible with the traditional ideal of professionalism.
This has implications for interprofessional working because joint-working is more difficult when there are supposed status differences between team-members. McCray writes some examples of this; Doctors may have difficulty taking advice from lesser qualified professionals, whereas nurses may not be confident enough to advise or provide information to them. Similarly, a social workers idea of good practice in mental health care may differ from a psychiatrist’s more medically orientated response. All this can create stress and tension between team members. Irvine et al state that ‘professional structures are differentiated by: demographics; the size of the occupation’s membership; gender composition; the class of origin of its members; educational attainment; status; and, the relative size and source of primary income.’ These differences are all cited as barriers to interprofessional working.
Traditionally, decision-making power has been in the hands of the ‘professional elite’. Medicine, for example, is a long established profession, whose membership consists mainly of well educated, high earning, upper-class males. On the other hand occupations like social work, occupational therapy etc are relatively new professions, recruiting mainly women from a variety of social classes with less educational attainment. These structural differences may contribute to a certain degree of defensiveness between occupations. Irvine et al claim that team working can actually reproduce and perpetuate inequalities in divisions of labour, status and authority, rather than promote more equal team working. Disagreements over power and jurisdiction cause a great barrier to effective interprofessional working.
Irvine et al also consider some organisational difficulties and barriers to the effectiveness of interprofessional practice. They identify that differences in working hours may hinder the development of close working relationships between professionals. Also the time different professionals take to carry out particular work may cause difficulties. For example doctors may be making decisions regarding clients on a day-to-day basis whereas social workers need to undertake longer term casework to meet their clients’ needs. Also, financial constraints can influence the ability of a team to practice effective collaborative working.
McCray notes that when budgets and resources are limited, the issue of who will pay for the intervention can also create tension within teams. Even if practitioners wish to work collaboratively, their managers may be less able to facilitate this due to budgeting constraints, and may therefore place restrictions on the amount of collaboration that can take place. An organisational difficulty which arose in our groupwork sessions was that at the time the sessions took place, which was the same time each week, some group members had already been in lectures etc all day, whilst some members had only just come in. This meant that some people were very tired and made little contribution to the group, and others therefore dominated much of the discussions and activities, creating an unequal dynamic. The situation may have been improved by having sessions at more varied times, giving different professions a chance to participate more equally.
There are also a number of cultural barriers to the effectiveness of interprofessional collaboration. Irvine et al say that language barriers exist between professions. Many professionals use obscure jargon that is inaccessible to those outside the discipline. This can be a source of misconception and misunderstanding between service providers. Terms used in one profession are often used by other professions; however these terms may have significantly different meanings and connotations, and entail differing responses from professionals in different disciplines. This can cause confusion in interprofessional collaborative work.
Irvine et al also point out that professional bodies tend to stake out boundaries between themselves and other professions. In order to maintain distinctive identities and protect their independence, professionals may be reluctant to share information with members of other professions. Therefore many professionals remain ignorant of other professions’ procedures and purposes, and have little knowledge of the demands their work places on them. This can cause a barrier to effective co-operation. Workers may set unreasonably high expectations of other practitioners, which will often lead to judgements of failure when their expectations are not met. An example of boundary setting between professions was identified within our group work, where in the earlier sessions, nurses sat on one side of the room while the social workers sat on the other.
The experience of working in an interprofessional team has benefited my learning. It has helped me to understand and see first hand some of the benefits and difficulties of collaborative working which I will face in my future career. As a team member I have learnt that I am sometimes quite passive, and need to develop my communication skills to enable myself to articulate more confidently my ideas and contributions. On the whole I feel that the topic of interprofessional working is very relevant to the effectiveness and efficiency of health and social care now and in the future. Inteprofessional working can bring many benefits, but there are also many barriers and hurdles that need to be considered and overcome to ensure that a high quality service is provided to service users.
Cook et al (2001) Decision-making in teams: issues arising from two UK evaluations. In Journal of Interprofessional care, vol. 15, No. 2, 2001
Department of Education and Science (1978) Special Educational Needs, The Warnock Report, London, HMSO
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Etzioni, A (1969) The semi-professions and their organisation. New York, Free Press
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McCray, J (2002) Nursing Practice in an Interprofessional Context. In Simpson, P. Hogston, R. (eds) Foundations in Nursing Practice. Palgrave 2002.
Scottish Office (1996) Children and Young Persons with Special Educational Needs: Assessment and Recording, Circular 4/96, Edinburgh, SOEID.
Sheppard, M (1996) Primary Care Roles and Relationships. In Watkins, M et al (eds) Collaborative Community Mental Health Care. London, Arnold